The Pulse October 2009

October 2009 VOLUME XXXIV NO. 4

Strong Team Leaders and Teamwork Score Victories Thomas A. Brabson, D.O., MBA, FACOEP

Presidential Viewpoints I sincerely hope that this issue of The Pulse finds you enjoying a happy and healthy autumn season. I also hope that those of you who were able to join us for an excellent Scientific Assembly enjoyed your time in Boston. The autumn scenery around Boston is a beautiful sight and the town is always bustling with activity.

I want to thank the Scientific Assembly committee, CME committee, the presenters and the ACOEP staff for delivering another exceptional educational program.

I also thank those participants that made the trip to Boston. We appreciate the time and effort it takes to attend our programs and always want all participants to go back home with new ways to enhance their practice of emergency medicine. Much time and effort is devoted by many people in developing and delivering our programs. We strive to provide the maximal benefit for all.

As we have moved into the fall, those of us who are sports fans, have plenty of opportunity to watch a variety of games. Baseball

has its championship, football has plenty of college and professional games, basketball and hockey are just getting started.

Depending on which team you support may make watching a game more or less enjoyable. Regardless, the real enjoyment of watching any of these sports is an appreciation of the way a group of individuals comes together to work as a team. Single games may be won by an outstanding effort of an individual player. Championships, however, are always the result of a cohesive team effort.

As osteopathic emergency physicians, we are members of many different teams.

We are members of the team that has been formed to provide care in our respective emergency departments. We are also members of the osteopathic team as well as the national healthcare team of emergency physicians. One question we need to ask ourselves is what we perceive our role is or should be on each team we are a member. I encourage each of you to seriously consider and realize that on any of your teams, you can be considered a ‘TEAM LEADER’.

In my opinion, being a team leader does not necessarily involve a title, designated responsibility or specified authority. The thought process and appreciation for the role begins by identifying the members of your team. The members may be individuals or categories of individuals. For example,

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when you are working in the emergency department, you are a member of the healthcare team for the patients that come to your emergency department for help.

The members of the team with that patient may include: the prehospital care providers, ED nurses, ED techs, ED registration, lab technicians, radiology technicians, ED physician colleagues, specialty consultants, and the admitting physician. Regardless of their proverbial rank, all have a significant role on the individual patient’s healthcare team.

As the emergency physician you are in the prime position to be the team leader. You can help coordinate everyone’s role in caring for the needs of the patient. It is an active process that works best when each member functions efficiently and effectively. The best way for that to happen is when each person’s roles and responsibilities are known and appreciated by every other member of the team. Unfortunately, sometimes this doesn’t occur. How often is the prehospital report not effectively communicated to the ED staff? How often do the physician and nurse not communicate their thoughts on what needs to happen for the patient? How often do any of the team members fail to keep the patient an active member of the team? How often do team members fail to assert a thought or idea because of perceived continued on page 14

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Editorial Staff: Drew A. Koch, DO, FACOEP, Editor Wayne Jones, DO, FACOEP, Assist. Editor Gary Bonfante, DO, FACOEP Thomas Brabson, DO, MBA, FACOEP Anthony Jennings, DO, FACOEP Janice Wachtler, Executive Director Editorial Committee: Drew A. Koch, DO, FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair Gary Bonfante, DO, FACOEP, Advisor David Bohorquez, DO Thomas Brabson, DO, FACOEP Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Brian Wiboon, DO Janice Wachtler, CBA The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, library of Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The PULSE and ACOEP accepts no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of the PULSE and will not be returned.

THE

The Pulse An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1500 Chicago, IL 60611-5277

PULSE O s t eop a t h i c

Emergency

Me d i c i n e

Q ua r t e r ly

Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, DO, MBA, FACOEP Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew Koch, DO, FACOEP Special Meeting of AOA Specialty Colleges and Boards . . . . . . . 6 Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Janice Wachtler, BA, CBA The On Deck Circle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Anthony Jennings, D.O., FACOEP Patient Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Gregory M. Christiansen, D.O., MEd Emergency Department Ethics . . . . . . . . . . . . . . . . . . . . . . . . . 10 Bernard Heilicser, DO, FACEP, FACOEP AOA Elects New President . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Guest Columnist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Wayne Jones, D.O., FACOEP

Display and print advertisements are accepted by the publication through Norcom, Inc., Advertising/Production Department, PO Box 2566 Northbrook, IL 60065 ∙ 847948-7762 or electronically at theteam@norcomdesign.com. Please contact Norcom for the specific rates and print specifications for both color and black and white print ads.

In My Own Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of the PULSE reserve the right to decline advertising and articles for any issue.

Events Calendar for September 2010 . . . . . . . . . . . . . . . . . . . . 20

©ACOEP 2009 – All rights reserved.

Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

On the Wild Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 James Shuler, D.O., MA, FACOEP How to Treat Your Body Like a Temple . . . . . . . . . . . . . . . . . . 18

EDITOR’s NOTE The next Edition of The Pulse will have an article on critical care medicine by Jeffrey Scott, DO, who is an Intensive Care Specialist at the Gulf Coast Medical Center in Fort Myers, FL. Dr. Scott has agreed to provide the readers of the Pulse with articles pertaining to critical care medicine. Possible topics and/or case studies for inclusion in The Pulse are: Pulmonary Embolism in Pregnancy; Nephrotic Syndrome with Acute Aortic Occlusion; Therapeutic Hypothermia from the ED to the ICU; and, H1N1 virus. DAK

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Editorial Drew Koch, D.O., FACOEP, Editor

Are You Ready For H1N1?

As the nation’s children return to school and summer is ending, there is a continued threat of the H1N1 virus spreading throughout our country. A busy, potentially deadly flu season is expected this fall as the novel H1N1 virus, the world’s first flu pandemic in 41 years, resurges at the same time the seasonal flu hits. The CDC estimates that 159 million individuals in the United States risk being infected by the H1N1 virus.

Those individuals at the highest risk of infection from the novel H1N1 virus are: • Pregnant woman • Household and caregiver contacts of children younger than 6 months of age • Healthcare and emergency services personnel • Children 6 months of age through 4 years • Children 5 years of age through 18 who have medical conditions that are associated with a higher risk of influenza complications • Individuals less than 65 years of age with diseases and chronic illnesses Individuals who are at high risk for complications from the H1N1 virus are: • Children less than 5 years old • Adults 65 years of age or older • Persons with following conditions: Chronic pulmonary, cardiovascular, renal, hepatic, hematological, neurological, neuromuscular or metabolic disorders Immunosuppression Pregnancy Persons who are less than 19 years receiving long term aspirin therapy Residents of nursing homes and other chronic-care facilities

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The first case of H1N1waa detected in the United States in April. Through the end of August 2009 the CDC has attributed over 9,000 hospitalizations and approximately 600 deaths. In July the CDC reported over 50,000 cases of the H1N1 virus.

The CDC predicts an increase of the H1N1 virus activity as the school year begins. It is incumbent upon us as emergency physicians to be ready for this epidemic.

The signs and symptoms of the H1N1 are similar to the seasonal flu and include: fever, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue.

Patients are contagious one day before their symptoms begin and may last up to 7 days of being sick.

Diarrhea and vomiting are also associated with H1N1. The H1N1 virus is spread the same way as the seasonal flu. The H1N1 virus is spread mainly from person to person through coughing or sneezing or touching infected objects or surfaces that have come in contact with the H1N1 virus then having an individual touch their nose or mouth.

Patients are contagious one day before their symptoms begin and may last up to 7 days of being sick. In children the symptoms may last longer.

Prevention of the H1N1 virus is the same as prevention of the seasonal flu and includes: • Covering your nose and mouth with a tissue when you cough and sneeze • Washing your hands after each patient contact with soap and water

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• Using precaution around patients with symptoms of H1N1 H1N1 may be detected in the Emergency Department with Rapid Influenza Diagnostic Testing. These results should be available within 30 minutes. A positive test for Influenza A indicates the likelihood of the H1N1 virus but a negative test does not rule out H1N1. Clinical judgment is an important factor for diagnosing and for treatment. The CDC has approved two antiviral medications for the treatment of H1N1. These medications are Oseltamivir and Zanamivir and should be administered with 48 hours of symptoms. These medications should be started as soon as possible.

Recommendations for the use of antiviral may change as data on antiviral effectiveness, clinical spectrum of illness, adverse events from antiviral use and antiviral susceptibility become available.

Not every person who presents to the Emergency Department with suspected H1N1 virus should be tested or treated.

Patients who present with suspected H1N1 influenza with an uncomplicated febrile illness usually do not require testing and treatment unless these individuals are at high risk for complications. Testing and treatment guidelines for the H1N1 virus may be provided in conjunction with your local and or state health department.

Treatment recommendations are: • All hospitalized patients with confirmed, probable or suspected H1N1 influenza • Patients who are at high risk for influenza complications If a patient is not in a high risk group for complications or is not hospitalized then health care workers should use clinical judgment to guide treatment decisions.

Patients with suspected H1N1 illness continued on page 13

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Special Meeting of AOA Specialty Colleges and Boards Held During Summer On July 16 during the AOA Annual Business Meeting in Chicago, Laurence H. Belkoff, D.O., FACOS, the President of the American College of Osteopathic Surgeons, moderated a meeting of the leaders of the osteopathic specialty colleges and the AOA certifying boards. The following leaders and staff were encouraged to participate: • Specialty college president, president elect, and executive director; • Certifying board chair, chair elect, and executive director; • AOA Bureau of Osteopathic Specialists (BOS) chair and staff; • AOA Council on CME chair and staff; and • Other interested AOA leaders and staff.

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The purpose of the meeting was to

discuss the implementation of Osteopathic Continuous Certification (OCC) and the relationships between the certifying boards, specialty colleges, and the AOA, and if and how these relationships should be strengthened. In prior discussions with leaders of specialty colleges and certifying boards, there was a concern about the resources necessary to implement OCC and questions about the role of the specialty colleges and the AOA in the process.

For example, a role of the specialty colleges could be to provide specialty specific CME required by the certifying board for OCC. A role of the AOA could be to provide more robust data bases for the certifying boards for on line testing, patient registries, etc.

On March 10, 2009, Dr. Ronald Ayres, Chair of the AOA Bureau of Osteopathic Specialists (BOS), sent a memorandum to

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the specialty colleges and certifying boards notifying them that the certifying boards were to submit their plans for OCC to the Bureau’s Standards Review Committee for review and approval by April 2010. Prior to this deadline, the certifying boards were to discuss their plan for OCC with their specialty college “to work out any difficulties.”

At the meeting, Dr. Ayres discussed the components of OCC. These components are: • Component I. Unrestricted Licensure • Component II Lifelong Learning/ Continuing Medical Education Component • Component III-Practice Performance Assessment ( CAP or similar process for continued on page 14

Executive Directors Desk Janice Wachtler

Ain't It A Pain?

It seems like physicians and health care providers worry a lot about patients in pain.

They ask you to rate your pain on a scale of 1 to 10, and look at your face to judge if patients are being stoic about pain. But my question is do physicians, dentists and other healthcare providers over prescribe and ultimately make some patients dependent on pain medications?

Recently on a visit to the dentist, I found that I had three teeth under bridges that had sustained damage, either an abscess or crack

that would cause me to have three teeth pulled on my next visit. After the tooth pulling frenzy and feeling no pain thanks to a nerve block, I inquired if I needed an antibiotic (not a pain medication). I was told “no” and sent on my merry way to gum things for several weeks until I healed enough to have implants and a new bridge implanted. Several days later I was still very swollen and my face and neck were hot. I called the dentist, relayed my symptoms and told to go to the pharmacy. When I got there he gave me 24 Vicodin pills. I sort of went nuts and called him from the pharmacy stating, I was managing my pain fine, but I thought I had some type of infection and would rather have an antibiotic.

He reluctantly called in a prescription for an antibiotic and in 10 days everything was

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fine. The problem, the pharmacy wouldn’t “un-dispense” the Vicodin, so it went home and it was mixed with my dirty kitty litter and disposed.

I called the dentist and asked why he wouldn’t give just give me an antibiotic? He stated because people are abusing the antibiotics! Well, hello aren’t people abusing pain medications too?

I then asked a physician neighbor (an internist) this question: If three people came into your office complaining of pain how would you judge their pain levels. He referred to the pain scale and facial recognition of signs of pain and then he would look at the patient’s chart and prescribe as needed. I then asked, if these patients were continued on page 16

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AOA Elects New President At the Annual Meeting of the House of Delegates, Lawrence Wickless, D.O., a gastroenterologist from Michigan was elected to the Presidency of the American Osteopathic Association. Dr. Wickless has been a long-time participant in the House of Delegates and Member of the AOA’s Board of Trustees. Elected to the position of President-elect was Karen Nichols, D.O. of Illinois. Dr. Nichols is the Dean of the Midwestern University/Chicago College of Osteopathic Medicine.

Nicole Ottens, D.O., Past President of the ACOEP Student Chapter was elected to the one-year position of Resident Representative to the AOA Board of Trustees. Dr. Ottens is currently in the 5th year of a combined residency in emergency medicine/family medicine at Midwestern University/Chicago College of Osteopathic Medicine.

The ACOEP will host Dr. Wickless, Dr. Nichols and Dr. Ottens at the 2010 Spring Seminar at the Kierland Resort and

Spa in Scottsdale, Arizona in April 2010.

We congratulate all of the newly elected members of the AOA Board and all the physicians who have been appointed to the various committees of the AOA.

The On Deck Circle Anthony Jennings, D.O., FACOEP President Elect

Sept 11, Shifting Gears, Heath Care Reform and Stuff It is hard to believe that we now are to 8 years post 9/11. Our world has now been changed dramatically. Our politics changed.

Our economy changed. Our nation changed.

And so did I. I reflect back on the changes which occurred in my life alone—I stepped out of a great job in a one of the coolest places for a young E.D. doc to practice. I left a great group and a great company. I elected to bring my family back to the midwest where my children would have interaction with family. I would be close to my parents again. My parents would regularly see their grandchildren. And my children would grow up with their cousins.

After eight years I have now changed gears again and decided to leave my administrative position/directorship. I will be joining a group of physicians that I am very excited to join. Most of my medical career has been spent in some form of administration. It was at times rewarding and times………not. My family has approved my decision. I will join a group of E.D. physicians at a highly respected hospital.

The new group is actually an “old group”

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which has many friends- former residents, former colleagues, and even my former residency director. I view my change as also a positive for the ACOEP in my upcoming years as I will have the opportunity to focus non- clinical time on my duties to the membership. I view the change as a win for us all.

Our health care reform is also changing and I hope for the good. As I type this we are just a few days post the presidential address to our nation’s schoolchildren. It sent the press into “a giant much ado ‘bout nothing” reporting the controversy. I am sure that not every person agrees with the president’s message, his tactics, or some portion of his actions but when we look at where we are at as a nation, where we have been over the last few years, and where we are headed it becomes clear- the old formula does not work. Our challenge will be to shape our future. This will occur only if we can unify as healthcare providers. If we can take the time, donate the money, and do what can to control our destiny. At the end of the day, end of the month, end of the

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year, end of whatever…..we must give time and money or be happy with whatever we end up with.

And finally another baseball season will have come to a close without the Cubs winning a world series. What started as a promising year imploded. I will be ready for spring training and the potential a new season will bring. Hey ……. I am a loyal Cubbie. A less than humorous nurse in our E.D. asked me if I knew what Jesus told the Cubs? I said I did not know what he may have said. With an evil grin she replied Jesus said “don’t do anything until I come back.” I simply smiled and said wait until next year!

Patient Satisfaction …

I’ll Give Ya’ Patient Satisfaction … Pilgrim …

I was sitting in our hospital’s physician dining room recently listening to the multitude of opinions as to what is wrong with health care. I heard a radiologist at the end of the table comment that “in his opinion, it was the emergency physicians ordering too many tests because they are afraid of trial lawyers and this was partially to blame for hospital based health care cost increases.”

My guns were immediately drawn. I stood up like John Wayne. I emptied all 12 from my imaginary 6 six shooters straight into the bastard! Of course that was only in my mind! What actually transpired was that I leaned forward and kicked into an educational mode. Dear sir I opened to the radiologist…….No emergency physician who has testes (or ovaries) ever worries about what the trial attorney thinks. Heads turned toward me. I continued on… E.P.’s

provide evidence based medical care. We do the right thing. We order the right test.

We admit the right patient. We order the right radiology exam…For in the end we are judged by doing the right thing and the right thing only (and documenting it!).

We provide the best care that we can at the time to help our patients. The problem is that sometimes the right thing is not immediately clear and we must run to the end of a few paths to get the right answers. And we do this most of the time.

The radiologist then pushed his tray back. The physicians at the table stopped eating. I know that deep down in the inards’ of those at the table they were secretly hoping for an all out brawl. What ensued was instead a “battle of wits.” You mean to tell me that you E.D. docs don’t order all of these tests to buff your charts for the attor-

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neys? You’ve got to be kidding he goaded. I have seen our number of CT scans increase twenty percent over the last 5 years. You can’t tell me that you guys don’t order all of those scans because you think you are doing the right thing! He paused thinking he had just shot me down……

Silence for a very brief second as I reloaded. There was now a sparked interest from the other 7 or 8 physicians who were seated around the table. Well Mr. Radiologist, I countered. One reason why our percentage of CT scans has increased twenty percent over the last 5 years is that our volume is now up 60 percent. We may in fact be under ordering from a statistical standpoint!

I continued. The reason that we order continued on next page

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Emergency Department Ethics Bernard Heilicser, D.O., MS, FACEP, FACOEP

What Would You Do? The following ethical dilemma case was posed by a Director of Security at a hospital in an urban environment.

If a hospital was being overwhelmed by an influx of patients, both by EMS and ambulatory self-referring, because of a scenario involving a mass casualty event, weapon of mass destruction or infectious etiology (i.e. H1N1), would administra-

Patient Satisfaction, continued from page 9 any unnecessary exams is surprising? Ears were open, eyes upon me. Interest was peaked. It is patient satisfaction scores!

There was a confused look from my antagonistic colleague who lives in the dark place.

The other dining docs waited. What do you mean patient satisfaction scores? He rolled his eyes. What is this patient satisfaction crappola??? How can you guys blame patient satisfaction???

I went on . . . Well; we do not really fear the attorneys. Emergency physicians fear the patient satisfaction scores. Because behind the satisfaction scores are hospital administrators; the suits. They are the ones who can hurt us financially. You see, any E.P. worth his salt can statistically do the right thing, statistically most of the time to avoid legal issues. Emergency physicians cannot control how the patient and their family will respond to all of the variables that go into the satisfaction questionnaire that they receive 4 weeks after their visit to the emergency department. If the receptionist was not nice . . . bad score. If the nurse was not nice . . . bad score. If the tech was not quick enough with coffee for the spouse . . . bad score. Wait too long for your vicodin . . . bad score. If the patient did not like the way you looked, talked, dressed, acted, or smelled . . . bad score. Get bad scores on your satisfaction and the hospital administrators get rid of you and possibly your

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tion of a placebo medication be appropriate? More specifically, if a patient is stable (worried well) and demanding diagnostics and treatment which may not be indicated or able to be addressed in a timely manner because of the crisis, should a placebo be given and instructions provided to return at a later date?

hospital that was “going under”, or at risk of actual physical attack by a frightened community?

What would you do?

Would this be ethical in the context of a

Please send us your thoughts and ideas (fax 1-708-915-2743). Every attempt will be made to publish them when we review this case in the next Pulse.

entire group. They will withhold bonus money, they will withhold cost of living raises, and they will put E.P.s out of work.

The patient satisfaction score will hang around your neck like a rotting albatross.

Suits will beat you with statistics from both sides of their mouths. You order too many tests….bad doctor. Order the right number of tests but satisfaction scores not good . . . bad doctor. The kicker is that our patients get to decide too frequently what is good care based on their perception of what good care actually is. Never mind that a vast majority of our patients do not understand the difference between a cat scan and a cat.

Between a pet scan and a pet . . . They come to the E.D. because their neighbor who is an LPN at the nursing home said that if you bump your head on a cabinet by the sink then you need a ct scan. And the neighbor emphasized that she seemed to really know her stuff!!! Patient’s too frequently order their own tests prior to ever coming to the E.D. and you better do what they want or . . . bad score!!

Mouths dropped open. I was looking around the room. I wondered had I crossed the line? Had I gone a bridge too far?

Did they understand my message? What were these physicians thinking? Still silence.

They were waiting to see what would come out of my mouth next.

Then I went on.

Back to your original statement Mr. Radiologist, we do order a few tests that are

unnecessary from time to time. We admit patients from time to time who do not need it. It is not out of fear of those money grubbing trial attorneys. It is out of fear of the suits from letting us go. Look I said to the radiologist, we do the right thing. If we really want to move forward, make satisfaction something that our patients can accurately evaluate and are qualified to evaluate.

Coffee, wait times, cleanliness, etc…But don’t expect them to be able to evaluate the medical care that was received. Let’s take satisfaction for what it is. Satisfaction scores are a popularity contest and really nothing more. To base reimbursement on a popularity contest is not evidence based. To base quality health care delivered on a satisfaction score is not evidence based. Let’s give the decision on what constitutes quality health care to outcome based measures. Let satisfaction measure something other than healthcare. Then we will not have unnecessary admissions, unnecessary testing, and waste. We will have real medicine.

The radiologist had become disinterested in the conversation. He bit off more than he wanted to chew and he knew it. I scanned the table and a few nodded their heads in agreement, a few had the lost look, and a few looked disappointed that there was not a brawl. Everyone at the table resumed eating. I blew the imaginary smoke from my imaginary six shooters, holstered my irons, and finished my lunch . . .

John Wayne Style.

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Guest Columnist Wayne Jones, D.O., FACOEP Assistant Editor

Bad Boys The rare individual understands the emergency department. The vast majority of people have little experience with emergency care. Within each community, emergency departments vary in patient volume and styles of care delivery. This creates diversity of experiences and expectations even for practicing emergency physicians. But, be rest assured, everyone has an opinion, from Aunt Millie to Senator Pelosi.

Patients (also include government and health leaders) find the ED a confusing environment. While popular TV shows have oriented the public to our “environment”, the experience is often sobering for the patient. Patients are fearful of their symptoms, and the ultimate disease, which

may be causing their illness. We have come to interpret their fear as aggression, advocacy and complaining. It does challenge us to remember it is not about us, but about their apprehension. We are confronted by this maladaptive behavior everyday, but we seldom recognize it as a patient coping mechanism.

We have a difficult job. It is not about that patient, but about all the patients. Our hospital uses Press Ganey to track patient experiences and help us understand the patient’s perception of care. Press Ganey noted in their 2007 Emergency Department Pulse Report the average ED length of stay was four hours, but satisfaction routinely dropped after just two hours. For every

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additional 10,000 ED patients, the wait time generally increased by 30 minutes.

The higher the ED volume (and time waiting), the worse the scoring. Patients, in general, were more content when there were fewer patients with which to “compete.” So for each additional minute we spend with a patient, we become more disliked by the rest of our patients. And sometimes, we become labeled the “bad boys”. Ironic!

What makes us the bad boys? Last January, on the cover of Health Leaders Magazine, was the photo of a physician riding a motorcycle. He was not wearing a helmet but a surgical cap. His license continued on next page

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In My Own Words Mary Mazza, D.O. This is a true story but not at all unique.

It was busy in the emergency department, about 2am.

The paramedics bring us a patient saying that she ran into a vet hospital with her two dogs…she was afraid one had been stung by something. On her arrival there, she was very short of breath and getting worse so 911 was called. When they arrived, she could barely speak. She went into respiratory arrest, was intubated and brought to us. That’s it. No name, no medical history, no allergies, no contact information…nothing. Luckily, she had a credit card tucked into her bra but it seems that she left her wallet either at the vet hospital or at home. My staff started with a Google search and a call to the vet hospital.

One of the dogs had a tag with a phone number. It was an out of town relative who was still not able to provide any medical history other than she was allergic to cats.

She called a local relative who subsequently went to her house and called us back reading off all the medication bottles that he could find. Slowly, we were able to gather some basic information while we continued our resuscitation.

have flash drives with pertinent medical information and demographics. There are others who know absolutely nothing about their medications or allergies or medical history. Then there are those who can’t even speak and, frequently, there is no one there who can speak for them. In addition, family members often know nothing specific about the patient and can offer only minimal assistance. Our society is very mobile, families are scattered and medicine has become very specialized. Communication is key and sorely lacking and it is the patient who pays the price.

A Personal Health Record (PHR) is the answer. Medical information in a portable, updatable format that is easily and securely accessed by the people who need it when they need it. Why is this idea so difficult?

There is everything to gain on both sides of the bed as well as by a healthcare system

This is a perfect example of why we need Personal Health Records. The story that I tell is not new or foreign to any one of us.

It happens every day in emergency departments everywhere. We have all met people who come in with folded bits of paper listing medications and some even come in with large folders filled with every piece of paper that they can find that may or may not have some important information on it. This is usually passed to a tech to see if they can sift through to find a medication list, problem list or maybe even an EKG, an xray report or some recent labs. Very few (2 or 3 in my 13 years of practice) actually

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that is screaming of redundancy and waste.

Studies have shown that electronic records and health information exchanges have the potential to drastically reduce costs at all levels. There are also studies that have shown that people of all generations are open to this and recognize the need for information sharing. The technology is here and available and safe…definitely more secure than a piece of paper tucked in a wallet and at least as secure as the ubiquitous credit card or ATM card that has become the accepted norm.

Health care in America is on everyone’s agenda. If we expect the same high quality and availability of care that we are privileged to be accustomed to, we need to make changes and be open to new things.

If this means that we, as medical profescontinued on page 15

On the Wild Side James Shuler, D.O.,MS, FACOEP, FAWM Editors Note: This is the introductory article from ACOEP’s wilderness expert, Dr. Jim Shuler.

He has graciously agreed to write articles for the Pulse on wilderness medicine. His article on “Bicycle Safety” appeared in the previous Pulse. His column will be titled, “On the Wild Side.”

Greetings from the Wild Side. This summer has been packed with various wilderness activities for me. At the end of June, I helped provide medical support for the Avon Breast Cancer 2-day walk in Summit County, Colorado. That’s an event where about 2,300 people decide they’re going to

raise money to fight breast cancer and walk 40 miles in 2 days to prove their resolve.

Many of you who have known me over the years know that supporting events like this is a passion of mine. A fascinating aspect of this particular event, held in Summit County, is that it occurs at an average altitude of 8,700 feet above sea-level. When participants run into trouble, the challenge is to figure out if the patient complaining of headache, nausea, light-headedness and general fatigue is suffering from dehydration, an acute electrolyte disorder, or acute mountain sickness.

What’s a doctor to do? The symptoms are the same but the treatment for each is different.

Additionally, the participants seeking medical attention all have varying degrees of blisters and the aches and pains of over-use injuries. Interestingly, the same

stubborn folks tend to repeat these events annually. I get many resounding hugs and “Hi, Dr. Jim!”s from the participants, to which I usually stare back blankly until they remove a shoe and then I immediately recognize them.

A month after the Avon Breast Cancer Walk, I attended the Wilderness Medical Society’s annual meeting in Snowmass, Colorado. As always the venue was packed with fantastic workshops, lectures and outdoor opportunities catering to a widerange of interests. Some of this information I will be sharing with you in the spring 2010 meeting.

In the spirit of sharing information to make us all better physicians, our editor, Drew Koch, asked if I would be willing to write a wilderness medical column in the continued on next page 17

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The PULSE OCTOBER 2009

13

Presidential Viewpoints, continued from page 1 lack of appreciation for their contribution to the patient care effort?

In Latin, the word doctor, (doctoris) means ‘to teach’. As an osteopathic emergency physician, I think you can be both a doctor and a team leader. My opinion is based on what I think the letters in the term ‘TEAM LEADER’ can represent. I submit to you that they can stand for: Teach Every Available Moment Listen Earnestly And Direct Everyone Realistically. Teach what you know or are thinking to the other members of the team regardless of their position on the team. Listen to what they are thinking and then together direct the

Special Meeting of AOA, continued from page 6 clinical assessment) • Component IV-Cognitive Assessment (requires a secured proctored exam) • Component V- Continuous AOA Membership Requirement Dr. Ayres said that the AOA will send a survey to the specialty colleges and certifying boards to identify OCC issues and concerns that need to be addressed by the AOA, specialty colleges and certifying boards.

On December 29, 2008, John Becher, Jr, D.O., chair of the AOA Department of Educational Affairs, sent a letter to AOA accredited CME providers regarding the development of criteria for CME programs to meet the requirements of certifying boards for the 50 hours of specialty credit.

The criteria were to be developed and reviewed at the April 2009 BOS meeting and, if acceptable, sent to the AOA Board of Trustees for consideration of approval in July 2009.

At the meeting, Michael J. Feinstein, D.O., AOA Council on CME chair, reported on the actions taken by the AOA Board of Trustees earlier in the day in regard to the criteria for CME programs to meet the requirements of certifying boards for the 50 hours of required specialty credit.

The Board adopted an amended resolution that states: “ Resolved, that credit for specialty CME provided by CME providers other than

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care of the patient. Each team member also must have realistic expectation of what their individual contribution to the effort should be and what is expected of the others.

The team leader approach can work with any team. It will foster good communication, cohesiveness and camaraderie among all members who ascribe to it. I think that this approach will also be necessary as we continue our evolution through healthcare reform. We need to maintain a leadership role on the national healthcare team as change occurs. If we hope to score a victory for the patients who present to our country’s emergency departments, each of us needs to appreciate our need to take a team leader role.

The ACOEP is here to support you in that role but we need each of you to be active participants in the processes as they evolve.

Also, I encourage each of you to consider taking an active leadership role within your ACOEP. True leadership skills are learned and then shared with others.

Your ACOEP continues to work closely with the AOA as legislation in Washington, DC is generated and revised that will effect our practice of emergency medicine. I encourage you to visit DO-Online, located at www.do-online.org, and click on ‘Advocacy’ and on ‘AOA priority issues’.

This is an easy and great way to follow the important issues.

the relevant specialty affiliate may only be awarded by the specialty board with jurisdiction; and be it further

ability through public reporting by means of various independent activities.

Then Dr. Weiss discussed the efforts to align the quality efforts and what may be the major trends in physician performance measurement and accountability in the next 5-10 years, including possible maintenance of state license, maintenance of certification and OCC, and private and public sector performance measuring and “value based purchasing” with public availability of data on physician accountability.

Next, a breakout session was held so that each specialty college and corresponding certifying board could meet to discuss how OCC could be implemented for their specialty. Then each specialty reported back with breakout session reports and recommendations.

It is anticipated that there will be another meeting of the osteopathic specialty colleges and the AOA certifying boards, after compilation of a survey designed to identify OCC issues that AOA plans to send to both the certifying boards and the specialty colleges, possibly in conjunction with the next AOA Board of Trustees meeting on February 5-7, 2010 in Chicago or an AOA “cluster meeting” in January.

Special thanks to Guy Beaumont, Executive Director of the American College of Osteopathic Surgeons for supplying this article to The Pulse.

Resolved, that physicians may petition the specialty certifying board’s CME advisory subcommittee on a case by case basis for exceptions to this policy; and be it further Resolved, that each certifying board be required to establish a CME advisory subcommittee. It is the responsibility of each subcommittee to monitor the compliance of CME programs with the criteria, which is determined by the subcommittee.”

The next presentation was by Kevin B. Weiss, MD, the President and CEO of the American Board of Medical Specialties, on “Measuring physician performance: National Trends in Physician Accountability.”

Dr. Weiss talked about two models for assessing physician performance and improving patient care, and then summarized the current national efforts to assess the performance of physicians.

These efforts to provide for accountability of physicians were in three areas.

The first was “professional accountability” by licensing boards and specialty boards and societies by means of license renewal, board certification renewal, accreditation programs, and patient registry programs.

The second was “purchaser accountability” by hospitals, purchasers, health plans and government through such means as annual contracting, credentialing, and physician profiling. The third was consumer account-

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Editorial, continued from page 4 should remain at home for 7 days or until they are symptom free for 24 hours or whichever is longer.

As Emergency Physicians, we will be the front line in providing health care for the suspected H1N1 illnesses. We need to partner with our local communities, health

Bad Boys, continued from page 11 plate read “ED DOC.” His leather jacket had a flaming cross and gold crown with the words “Emergency Department, we roll our own way.” The photograph was taken outside of his place of employment… an ED. The lead story was “Why is the ED such a pain?” Now I ask you, who do you think reads Health Leaders Magazine?

Healthcare leaders! And, sadly, this is how we may be perceived.

How we see ourselves may be different from how we are viewed by others. Let me give you an example. The Roanoke Times ran a story in 2004 about Melissa, a young expectant mother. She feared that the sound from road construction outside her home would harm her unborn child. The news reporter took a picture of Melissa, outside her home, in front of the torn up roadway.

She was smoking a cigarette. Clearly, both of them shared the same environmental situation. Do you think they both shared the same perspective?

Patients watch us, all day, every day.

Not realizing what we are actually doing, patients interpret our actions as best they can. The visual clues we display tell much of our daily tale, followed secondarily by

In My Own Words, continued from page 12 sionals, have to accept and adapt new technology in our departments, then so be it.

Interoperability solutions among disparate EMR systems are now a reality. We need to make this work by promoting and supporting the use of personal health records, electronic medical records and health information exchange. We must expand our scopes and incorporate more than just our worlds

department, medical staff, hospital and Emergency Department in planning and providing health care for H1N1 or any other influenza like illness that is prevalent in our communities. There have been daily updates on our state department of health’s website, webcasts, meetings, and conferences all in preparation of the predicted increase in H1N1 virus when

schools are back in session. Information and recommendations about H1N1 are constantly changing. It is important that Emergency Medicine Physicians check with our local DOH and CDC about new recommendations and updates. Two excellent sources of information about H1N1 and flu, respectively, are www.cdc. gov/h1n1flu and www.flu.gov.

voice inflections and lastly by what we say.

Therefore, not even given the opportunity to hear our words, patients interpret our intent and meaning by these other clues.

We tend to be seen as everyone’s department. Historically and through our welcoming of all attendings to our department, we have created this sense of diffuse ownership.

Not only do other specialties see us as their “clinic”, but they feel comfortable recommending changes that would benefit them.

We truly live in a fish bowl. Our actions and inactions, along with our practice style and deficiencies are seen and judged by many people. This makes our jobs harder and yet to some degree liberating. Strength can be shown through transparency and disclosure.

I guess the hardest pill for me is accepting these judgments and criticism. I have been known to travel through the five stages of grief; denial- “not me”, anger“maybe it’s you”, bargaining- “God, don’t let them send this through quality review”, depression- “damn, damn, damn”, and acceptance- “crap”. Sometimes I make this trip all in one day. Sometimes I slobber over myself for much longer.

The recent debate over how to improve healthcare often puts the ED in the head-

lines. I still do not believe that the government really understands what we do. By law, we see everyone who ventures on our property. By ethics, we treat everyone the same. By virtue of these first two, we accept much less compensation but accept all the risk. Maybe we should not be the point of healthcare debates.

Emergency department visits grew by 20 million from 1995-2006. In the 2008 GAO report on overcrowding, 4600 of our nations ED’s were at or above capacity. The Annals of Emergency Medicine, in an article sponsored by the CDC, noted that less than 13% of patients arriving in our nations ED’s could be classified as non-urgent. Throw in that emergency physicians lose an average of $138,000 in bad debt yearly while our specialist colleagues lose only and average of $25,000, and we can start to see the real healthcare divide.

Emergency medicine has come a long way to becoming a respected professional organization; we just need to complete that journey. We need to help patients, our health center leaders and government officials understand that we are not the bad boys.

into the big picture that is healthcare. This may be different, this may be difficult, this may be frightening but this is necessary and will serve us all.

records, health information exchange and a concierge electronic medical record solution for outpatient practices. My Medical Memory is looking forward to playing an important role in ushering in the new expectation of improved communication and patient safety while reducing the redundancy and costs that are choking our current health care system.

Mary Mazza, DO is a practicing emergency physician in Gilbert, AZ and the founder and CEO of My Medical Memory (mymedicalmemory.org). In partnership with an IT company in Washington, DC, they offer personal health

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Executive Director, continued from page 7 of different ages, body builds, weight, and sex, would you prescribe the same dosage of medication; the answer maybe.

If someone walked into your emergency room, how would you prescribe for pain?

Supposedly, someone in my neighbor’s situation would be prescribing to a known group of patients. He would have their chart in front of him, know their medications, previous illnesses, and previous reactions to certain medications, but would you?

Suppose for an instance, that a man, 30 years old, of average weight and heights comes in complaining that he fell off a ladder cleaning out his gutter. On the pain scale he says his pain is about a 7 and facial recognition indicates that he is being stoic and looks like he is in much discomfort.

He has a sharp pain in his back and after x-rays and other diagnostic exams you find that he has no breaks, and a severe muscle pull and bruising. You take his history and he has no history of drug interactions, and is currently on no medications except for a statin for high cholesterol. You prescribe 50 mg of pain medication and tell him to see his family doctor the next day.

That same day a woman in her 40’s arrives at your ED, she too has fallen and is complaining about back and hip pain.

On the pain recognition scale she says her pain is a 10 plus, but her facial recognition doesn’t indicate that amount of pain.

Upon examination, x-rays and such, she has no fractures. She is of small stature and extremely small frame, weighing only 98 lbs. She is on no medications except hormones; would you give her the same dosage of pain medication?

Finally, an elderly woman comes in, she too has fallen getting out of a chair, she has some discomfort in her back and hip, but she informs you she only came into the ED to prove to her daughter that she’s OK and can stay home alone and doesn’t need to go into a senior living situation. On the pain scale she says that it’s about a 2, but upon palpation, her facial recognition indicates that she is in more pain than she wants to admit to. Examinations reveal that she has a large hematoma, but no breaks; she is on a lot of medication, including some for high cholesterol, high blood pressure and incontinence. Do you prescribe the same dosage

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of pain medication for her?

While I am not a physician, or a healthcare provider, I would say in most instances in relation to the scenarios above, some type of medication for pain would be administered and most likely the three patients would walk out of the ED on similar dosages.

I ask these questions for several reasons.

The first is can physicians and healthcare workers, in general, know for certain the level of pain that patients are in based on the pain scale and facial recognition tests. Since pain is so subjective and based somewhat on the stoicism of patients can you be sure that you are medicating their pain adequately and not over medicating? Secondly, should there be other tests done before medications

are disbursed? And, finally should there be a scale developed that providers healthcare providers who prescribe with a guide to dispensing medication based on body type and age.

If pain medications are not regulated and dosages adjusted, could this be the jumping off point for addiction to pain medication? Could this create someone who when on pain medication is suddenly sleeping better and feels the need to seek other similar narcotics to make the world go away?

I guess this will have to be someone else’s research but it sure seems that some guidelines are needed.

Is Your Company Looking to . . .

Reach New Markets?

Find Job Candidates?

Identify Qualified Faculty?

We can help.

The ACOEP has mechanisms available for vendors that include reasonable advertising rates; exhibit and sponsorship availability all to help those wishing to reach Emergency Medicine Physicians and Residents.

Contact ACOEP for further details at 1-800-521-3709 and ask for Yvonne Treacy

The PULSE OCTOBER 2009

On the Wild Side, continued from page 13 Pulse. I happily agreed and gave him a writing sample: an article on cycling with the family I had written for another magazine. Drew liked it, and--poof! It appeared in the last issue of the Pulse, and I hope you enjoyed it.

Gear-shift time. Another hazard of summer wilderness activities is good ol’ Mother Nature, and depending on where you are in the United States, you will see varying numbers of patients presenting with the classic signs and symptoms of plant-induced dermatitis caused by the Toxicodendron species commonly known as poison oak, sumac and ivy. Until recently we approached this refractory little condition with topical and oral steroids. One of the main reasons for treatment failure was inadequate duration of oral steroids. In order to resolve this uncomfortable affliction, we sentenced our patients to 10 days of oral steroids. For many, however, the side effects of the oral steroids were almost as bad or worse than the dermatitis itself.

Good news. There is a new product available to treat those nasty little dermatitises called Zanfel® made by Zanfel Laboratories (www.zanfel.com). Zanfel® is available over the counter and comes in the form of a cream. It is simply mixed with water, made into a paste, and applied to the affected area for 3 minutes. Then you rinse it off and voila! You’re done. Generally the symptoms of pruritus and pain are resolved within 30 seconds. In some refractory cases a second application 24 hours later may be required. The active ingredients in Zanfel® are simply detergents that bind the plant’s irritating phenolic oil, urushiol, that causes the type IV cellular-mediated reaction, renders it harmless and washes it away.

Generally it is the only treatment needed obviating the use of oral steroids.

As the changing seasons bring changing topics of concern, I hope to keep my “Wild Side” an open forum. I welcome requests on subject matter that you would like to hear about or questions you may have regarding situations, treatments, new products and the like. I welcome your notes, thoughts and comments via email at shulers@aol.com.

Emergency Medicine Program Director Position Announcement Grandview Hospital located in Dayton , Ohio is currently seeking a new Program Director for the Emergency Medicine Residency Program.

The successful candidate should possess ethical leadership and management experience, a commitment to education, advanced understanding of healthcare technologies utilized in the ER, and the ability to build constructive relationships with multiple constituents at that national, state and local level.

The Program Director will report directly to the Director of Medical Education and should be willing to actively participate in the Post Graduate Medical Education Committee.

The Program Director will be responsible for: • Providing overall leadership to the EM Residency Program • Coordinating and participating in the Didactic Program for the EM Residency Program • Managing the Clinical Curriculum for the EM Residency Program • Participating in the Budget Development Process with the Department of Post-Graduate Medical Education • Coordinating the recruitment, interview, and selection process for the EM Residency Program • Adhering to the AOA and ACOEP basic documents First consideration will be given to applicants who meet the following qualifications: • Willing to become board-certified osteopathic physician licensed to practice in the state of Ohio • An active member of the American College of Osteopathic Emergency Physicians (ACOEP) • An experienced educator with five years of practice experience preferred • Enthusiasm for creating and maintaining an Emergency Medicine program that is ranked among the highest in the osteopathic profession.

• Willing to maintain personal growth through continuing medical education in the field of medical education and his/her selected field of certification.

• Possess excellent management, organizational and leadership skills Interested applicants should direct inquiries to Robert Cain, D.O., Director of Medical Education at 937-723-3248 or Bradley Hobbs at Bradley.Hobbs@ khnetwork.org <mailto:Bradley..Hobbs@khnetwork.org>. For additional information on Grandview Hospital and the Kettering Health Network, please visit: http://www.khnetwork.org/ <http://www.khnetwork.org/>

The deadline for submitting your Curriculum Vitae is November 15th, 2009.

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How to Treat Your Body Like a Temple OR Fat, Fitness and Lifestyle

Listen, your mother always told you how to live your life: eat right, exercise, get a good nights rest and don’t let things bother you. Well, she was right. And if you are like most people, you didn’t listen. So now here you are, reading this article, either hoping to validate your lifestyle or look for some easy pointers. Either way, our modern society makes doing the right thing much more difficult.

How about if we take a snap shot of your day and see how things go.

Wake up at 5:30 (already exhausted because you had to see the late movie), watch the morning news, drink a cup of coffee, sneak a piece of the apple pie left over from dinner and take a shower before heading out to work. You have consumed over 300 calories, 11 grams of fat and 200 mg of caffeine.

On the drive to work, since you again feel hungry, you swing into Starbucks and order a venti size bold coffee and one donut (I am treating myself special today).You consume an additional 400 calories and 19 grams of fat with 320 mg of caffeine (I will go to the gym tonight).

You arrive at work, feel frustrated over your multiple job stressors and decide to pick up lunch (well, Ok, you always pick up lunch). You decide to be “good” and go to Subway (eat fresh) and order the turkey bacon sandwich with southwest sauce and a can of jolt cola (I know, I know). Chock up another 579 calories with 25 grams of fat and 72 mg of caffeine.

What a day! It’s finally over and you drive past the gym. But you promised yourself you would stop (I’ll stop tomorrow). You swing into Panera’s for dinner (who feels like cooking now?). You order the Greek salad and a bowl of French onion soup (nice and light). You drive home and consume the 740 calories with 58 grams of fat and 3370 mg of sodium.

18

You still feel stressed so you tune back into the movie channel for the evening.

You finish the last slice of apple pie.By midnight you are exhausted and you roll into bed for the night. “I’ll do better tomorrow,” you think.

So how did we do? Well, you consumed a total of 2419 calories (not bad for a lumber jack), 124 grams of fat and just enough caffeine to keep you up until midnight. And, oh yes, no exercise. But wait, there is always tomorrow.

This probably sounds, at least to some degree, familiar to all of us. We call it

Evidence is rapidly mounting to indicate that chronic sleep loss may increase the risk of diabetes, higher body mass index and obesity. “lifestyle.” But we need to step back and not only try to enjoy today but plan for tomorrow.

Sleep is becoming a better understood component to our “healthy” lives. Over the past few decades the trend towards sleep deprivation has mirrored the dramatic increase in obesity. Evidence is rapidly mounting to indicate that chronic sleep loss may increase the risk of diabetes, higher body mass index and obesity.

Research is also elucidating the effects of stress on the body. Chronic recurrent

The PULSE OCTOBER 2009

stress stimulates the release of multiple neurotransmitters which allow for fat deposition and cardiovascular atherosclerosis. In total, the effects create a ripe environment for obesity, diabetes, hypertension and heart disease.

Nutrition is an article all to itself.

Understanding what we eat not only as a culture but as an individual is the first step in reigning in the threat of obesity and the many other diseases that follow. Taking time and preparing our meals at home provide much more flavorful meals along with limiting the processed fats and chemicals inherent in commercially prepared foods. To do this requires us to plan ahead and reduce the “stress” of cooking for ourselves.

Finally, we would not be complete without discussing fitness and exercise. The Centers for Disease Control recommend adults should increase their activity to 300 minutes of moderate exercise or 150 minutes of intense exercise per week. Moderate activities include walking, water aerobics, riding a bike playing tennis or mowing the lawn. Intense exercise includes jogging swimming, and playing basketball. All in all, any activity can be considered exercise and will add to the quality of your life.

Notice I have not discussed alcohol consumption and cigarette smoking. Come on, what were you thinking?

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Presorted Standard U.S. Postage

PAID

Chicago, IL Permit No. 2177 142 E. Ontario Street Suite 1500 Chicago, Illinios 60611

Event Calendar 2010 January 6 – 11

January/February 31 – 2

March 4

20

April

Emergency Medicine: An Intense Review The Westin River North Hotel Chicago, IL 42 hours Category 1/1A

6 – 10

October

Program Directors Faculty Development Workshop and Symposium Marco Island Hilton Resort & Spa Marco Island, FL 8 hours Category 1A Oral Board Review Location TBD Chicago, IL 10 hours Category 1A

Spring Seminar Westin Kierland Resort & Spa Scottsdale, AZ 25 hours Category 1/1A*

23 – 28

Scientific Assembly Hilton Hotel – San Francisco San Francisco, CA

23 – 24 24 25 – 28

Committee Meetings ACOEP Membership Meeting Scientific Assembly Hours undetermined at this time

* ACEP Accreditation pending

The PULSE OCTOBER 2009